There has been considerable concern over the past few years regarding the expansion in the amount of medical information available in general as well as with respect to individual patients. At the same time as there are increasing pressures on health care workers to document as fully as possible, there are pressures to provide care as efficiently as possible. In general, care is given to a patient and the health care worker afterwards writes a note in a chart, or dictates a note, describing the activity. This information is “inscribed” in a relatively free form fashion. While this is useful and important as a way of preserving certain kinds of clinical information, it impedes medical care at other times because of the lack of standardization of terms and concepts. Finally, when notes are hand written they are often difficult for others to read.
Increased documentation is being requested by third party organizations. The lack of structure to medical notes often results in an increase in accounts receivable for care givers (that is, an increase in the backlog of bills which haven't been paid). This is because questions are asked about a rendered service, the chart needs to be found, the appropriate information extracted, and information sent back to the payer. Individual practitioners, academic institutions, pharmaceutical companies, and others in the health care industry have an interest not only in gathering patient related information but also in assessing the quality of the care, and in developing new methods of care. The Health Care Financing Administration (HCFA) a branch of the United States Department of Health and Human Services, in keeping with this trend, has published, in conjunction with the American Medical Association, a list of detailed requirements for billing at various levels.
Health care providers would like to document the care they give as efficiently and accurately as possible. However, today a health care worker typically must indicate the results of the encounter, given current methods, after the patient is seen. This increases the burden on the individual health care provider. It increases the cost of gathering the data, regardless of whether information is entered by the original provider or by someone else. Because memory is faulty, even recent memory, it increases the likelihood of errors (both mis-statements and omissions).
There has been a general increase in automation over the past several decades as a way of meeting some of these needs. For medical care, a number of companies have developed electronic medical information repositories. On the simplest levels, these repositories, often called electronic medical records or electronic patient records, include clinical notes, discharge summaries, and operative notes, all of these the result of dictation. Laboratory reports also are typically included. The advantage of these repositories is that notes are in a legible form since they are dictated by the practitioner and then “typed.” Moreover, they are stored in a common repository so that it becomes easier to find all the information, or at least much of the information, on a given patient. The disadvantage is that the information in many implementations is free form. Thus specific items of information are harder to find. This in turn means that the goals of clinical studies or clinical research are not met. If payers request specific kinds of information the information must be sought by a close reading of the text with automation relatively difficult. If information is to be obtained, diagnoses made, and care administered according to a protocol, there is no way of ensuring that this has occurred in the case of an individual patient without actually reading the record. Finally there are no ways of enhancing or facilitating data entry. Even though dictation is faster than writing, it usually is done at a time after the patient is seen and can be quite time consuming. To meet these needs, a number of companies have introduced systems for entering medical information through the use of organized menus. The user chooses from a list or lists the items pertinent to the visit. The computer program then develops a chart note based upon the choices entered. The disadvantage of this has been a lack of physician acceptance: many feel constrained by the programs, feel that they are more time consuming than dictation, and that the available choices do not reflect important aspects of the patient encounter.